Dr M.S. Ibrahim, Bsc, MBBS, FWACS (Rad)Department of Radiology, UITH,Ilorin

INTRODUCTION

• An adnexal mass refers to a solid or cystic space-occupying lesion from either the ovaries or tubes

• Most often, adnexal masses develop from the ovaries, and are called ovarian cysts or ovarian masses.

• The vast majority of patients of all ages diagnosed with ovarian masses, cystic or solid, are usually benign.

• Patients near menopause or past menopause have a higher rate of cancer within an ovarian mass.

• In general, patients greater than the age of 40 do have a higher risk of ovarian cancer, and must have masses treated sooner to ensure that cancer is not present.

• Clear cysts to the ovary have a much lower incidence of cancer, whereas complex masses have a higher incidence of being cancerous.

• A complex cyst is any mass to the ovary having solid and/or cystic components with septations or excressances in the ovary.  Septations are bands or divisions between multiple cysts within the ovary, whereas excressances or mural nodules are growths either on the inside or outside of the ovary.

Clear Cystic Masses

• These fluid collections in the ovary are almost always benign at any age.

• Usually present as follicular cysts in reproductive age women. Follicular means the cyst originated from the follicle, or cyst containing the egg, within the ovary.

• Follicular cysts form either due to nonovulation, or non release of the egg, with persistence of the cyst or from reformation of the cyst after ovulation.

• The incidence of cancer is very low in these cysts. • Most can be followed by ultrasound unless they

become larger, at which point surgery is usually required.

Solid Masses

OVARIAN FIBROMA -The most common purely solid mass to the ovary.

DYSGERMINOMA- Hormone producing solid mass of the ovary. A common solid tumor to the ovary in younger patients .

Complex Masses to the Ovary

• Most patients with masses to the ovary have complex structure, meaning the mass is not a clear cyst but has solid components, septations, excressances, or “thick fluid” type areas described by ultrasound as “hypoechoic.”

• Any complex mass with any of the above features in patients greater than 40 must be evaluated immediately to ensure that cancer is not present. 

• Any complex mass in a patient less than 40 that is enlarging and suspicious must be evaluated to ensure cancer is not present.

Types of Complex Masses

• Dermoid cysts. • Hemmorhagic cysts. • Endometriomas. • Serous and Mucinous Cysts.• Serous and Mucinous Cystadeno

Fibroma.• Germ Cell and Stromal Cell Tumors,

Low Malignant Potential (LMP)Tumors.

• Malignant ovarian Tumours.

DERMOID CYSTS

Most common complex masses of the ovary.

Benign in the vast majority of cases. Only 1% or less are malignant.

HEMMORHAGIC CYSTS

Bleeding occurs within the ovary, leading to the formation of a blood clot or hematoma.

Usually develop from follicular cysts that have released the egg, with the rupture of egg  causing bleeding and development of a blood filled cyst.

Usually resolve but may require surgery in cases of severe pain or excessive growth of the cyst.

ENDOMETRIOMAS

Develop from tissue of the cavity of the uterus, called the endometrium.

Develops through movement of tissue from the endometrial lining (from the uterine cavity) through the tubes and implanting on the ovary.

Collections of old blood and endometrial tissue that grow monthly through estrogen production.

They are usually always benign.

Serous and Mucinous Cysts. These cyst types are also very

common. Serous cysts are composed of thin

fluid. Mucinous cysts composed of thicker

fluid and shows fine or coarse internal echoes

They are usually benign, and present as complex masses.

Serous and Mucinous Cystadeno-fibroma

• Serous and mucinous cysts combined with solid fibroid growth on the ovary.

• They are considered as complex masses, due to the combination of solid and cystic components .

• Usually benign.

Germ Cell and Stromal Cell Tumors, Low Malignant Potential Tumors (LMP)

. 

Most of these tumors are benign, but low grade malignancy does occur within this group.

Low grade malignant tumors are generally considered benign, since they do not spread from the ovary in most cases.

Germ cell, stromal and LMP tumors .

Germ cell, stromal and LMP tumors They are in general very rare. Diagnosis can only be made with

evaluation of tissue from the ovary. The most common germ cell tumor is

a dysgerminoma, usually occurring in younger patients.

The most common stromal cell tumor is a granulosa cell tumor occurring in patients of all ages.

Malignant Ovarian masses.

• Ovarian cancer is a rare disease, with an incidence in the entire population of 1.4%. Patients diagnosed with ovarian cancer are usually between the ages of 50 and 70. Within this age range, the incidence of ovarian cancer is higher.

• Complex masses or solid masses of the ovary must be ruled out for ovarian cancer. This is a priority in patients greater than the age of 40, or in any patient less than 40 in which a complex mass of the ovary has NOT decreased in size with follow up ultrasound.

• Ultrasound, MRI, or CT scan cannot make the diagnosis of malignancy. The reason for this is that the diagnosis has to be made ‘histologically”, or through a diagnosis of the tissue from the ovary, which requires surgery.

• Since ovarian cancer has much higher success rates for long term survival in the earlier stages, it is important that complex masses be evaluated, followed closely in certain patients, or removed to rule out ovarian cancer and prevent progression of disease to higher stages. Stage I disease, for example, has five year survival rates in the range of 75 to 95%.  Most patients diagnosed with ovarian cancer are stage IIIc, an advanced stage that leads to survival rates as low as 10 to 20% over a 10 year period. 

SYMPTOMS

• Pain. • Abdominal Distension- with Back

Pain, Constipation, Bowel and Stomach Symptoms.

• Pelvic Pressure- Very large masses will eventually compress the bladder, decreasing the capacity of the bladder causing frequent urination.

• Weight loss

Diagnosis

• Ultrasound remains the best method to identify and “characterize” ovarian masses.

• MRI is also useful in some cases in which ultrasound is indeterminate, but should not be used as the primary method for characterization of ovarian masses.

• CT scan is less reliable than either MRI or Ultrasound, but can be used to help with the diagnosis of advanced ovarian cancer.

USS TECHNIQUE

TRANSABDOMINAL- with 3.5mhz probe patient in supine position with full bladder.

TRANSVAGINAL- with 5.0mhz probe patient in lithotomy position with flexed hip and knees, empty bladder.

Technique of tvus

To facilitate the performance of this test, the patient has to be well informed of the procedure, its benefits and what to expect during and after the examination. Allergy to latex materials must be elicited, so that the use of latex gloves and coverings may be avoided.

The patient prepares for the procedure as in a pelvic examination. She is asked to avoid taking fluids a few hours before the examination, and urinate to empty her bladder and avoid discomfort during the procedure.

Then, she is asked to undress from the waist down and is covered with a hospital gown or blanket. The patient then lies down on her back, with her feet resting on stirrups. She is asked to relax, lie still and breathe normally.

The examination usually takes only 15-30 minutes and no special after care precautions are needed. Infection is rare.

Clear ovarian cyst(benign)

Leading follicle in a normal ovary

Follicular cystWell defined rounded hypoechoic adnexal structures

Luteal cystWith a co-existing intrauterine gestation.

Corpus luteum cystSpectral doppler showing low mpedance flow

Hemorrhagic cystWell circumscribed with multiple echogenic strands and fluid showing internal echoes

Hemorrhagic ovarian cystColour doppler showng the vascularity of the mass

Endometrioma (chocolate cyst)Well circumscribed with homogeneous echoes.

Ovarian hyperstimulation syndromeOHSS

Polycystic variesPCOS

Ccalcified ovaryRounded well-circumscribed with echogenic rim.

Complex ovarian massHeterogeneous mass with solid /cystic components and septations

Complex massr/o malignancy

Mucinous cystadenomaMultiloculated with echogenic strands .

Serous cystadenomaSolid area with septations and fine internal echoes.

Serous cystadenomaEccentric solid area with fine internal echoes

Serous cystadenomaColour Doppler

Ovarian fibromaSolid mass with homogeneous echotexture

Ovarian dermoid(benign)

Dermoid cystWith a floating echogenic area due to fat

ACUTE PELVIC INFECTIONThick-walled left tub-ovarian abscess with POD fluid

HydrosalphinxLobulated hypoechoic structure adjacent to the ovary

DIFFERENTIAL DIAGNOSIS

>Acute / chronic tubo-ovarian abscess.> Pedunculated fibroid - Differentiation

from an ovarian mass depends on identification of the ovaries separately.

> Ectopic pregnancy- Extrauterine GS or positive serum/urine HCG

> Other inflammatory masses-e.g. appendix or diverticular mass.

> Other neoplastic masses-e.g. arising from the bowel or peritoneum.

Summary

a) Ultrasound remains the best method to identify and “characterize” ovarian masses. (The first court of competent jurisdiction)

b) Complex masses or solid masses of the ovary must be ruled out for ovarian cancer .

c) The sample from the patient has to be taken for histological evaluation for definitive diagnosis. ( supreme court)